CBR for 24-48 hours Coitus is restricted for 2 weeks after bleeding has stopped Advise the patient to save all pads, clots and expelled tissues

2. Imminent/ Inevitable
Symptom:
Bright red vaginal bleeding which is moderate in amount and accompanied by uterine contractions and cervical dilatation. Loss of the product of conception is Inevitable.

Management- depends on
whether it is

Complete abortion- all products
of conception are expelled; bleeding is minimal and self-limiting. No intervention is therefore needed.

Incomplete Abortion- part of
the conceptus ( usually the fetus) expelled, but membranes or placental fragments are retained. D & C is indicated as management

7 week old baby

8 week old fetus

3.

- fetus dies in utero but is not expelled -Usually discovered at a prenatal visit when the fundic height is measured and no increase is demonstrated or when previously heard fetal heart tones are no longer present. -At 2 weeks time , signs of abortion should occur ; otherwise, labor will have to be induced to prevent hypofibroginemia or sepsis.

Missed abortion

b. Induced abortion
is never allowed in the Phils

Therapeutic
performed by a doctor in a controlled hospital or clinic setting for a medical or legal reason. Also known as medical, planned or legal abortion

Illegal

9 week old fetus

First trimester

First trimester in womb photo

Second Trimester

Second trimester in womb photo

Third Trimester

Third trimester in womb photo

ECTOPIC PREGNANCY
= any gestation located outside the uterine cavity
Signs and symptoms
severe, sharp, knife-like stabbing pain in either the right or left lower quadrant Rigid abdomen (+) Cullen’s sign- bluish umbilicus

Risk Factors
1.Pelvic inflammatory disease (PID), gonorrhea, or chlamydia (which may be symptomless) - Rate of ectopic pregnancy in women withprevious known PID is increased 6-10 times higher than in women with no previous history of PID. A published study of 745 women with one or more episodes of PID that attempted to conceive showed that 16% were infertile from tubal occlusion. Of those that conceived, 6.4% had ectopic pregnancies. 2. You've had a previous ectopic pregnancy

3. You have an intrauterine device (IUD) in place when you get pregnant. (IUDs are about 99 percent effective at preventing pregnancy, but if you do get pregnant while using one, the pregnancy is likely to be ectopic. Having used an IUD in the past will not increase your risk for ectopic pregnancy.) 4. Your tubes were damaged by a previous infection or surgery.

Management
- ruptured ectopic pregnancy is an emergency situation

Salpingostomy- if Fallopian Tube can still be replaced and preserved; but the pregnancy has to be terminated Salpingectomy- removal of the Fallopian tube + blood transfusion Nursing Care- Combat Shock
Elevate foot of the bed Maintain body heat by hot water bottles and blankets

Different Procedures used:
•Salpingotomy (or -ostomy): Making an incision on the tube and removing the pregnancy. •Salpingectomy: Cutting the tube out. •Segmental resection: Cutting out the affected portion of the tube. •Fimbrial expression: "Milking" the pregnancy out the end of the tube. In general, the procedure of choice will be salpingectomy if future fertility is of no concern, if the tube is ruptured, if there is significant anatomic distortion, or if there is overt hemorrhage.

Abdominal Surgery- In this case, you'll be given general anesthesia and a surgeon will open your abdomen and remove the embryo as well as the ruptured tube, if necessary. You may need a blood transfusion to replace lost blood if you were bleeding heavily before surgery. Afterward, you'll need about six weeks to recuperate. You may feel bloated, and have sore breasts and abdominal pain or discomfort as you heal.

Medical Management with Methotrexate If the hCG level is below a certain limit and there is no risk of imminent rupture, the doctor may prescribe a drug called methotrexate to treat the ectopic pregnancy. Methotrexate is also used in chemotherapy and works to stop rapidly growing cells from multiplying. The drug is administered as an injection.

SECOND TRIMESTER BLEEDING

1.

HYDATIDIFORM MOLE

- developmental anomaly of the placenta resulting in proliferation and degeneration of the chorionic villi S/Sx- Because of rapid proliferation of the placental tissues and therefore, high levels of HCG -Highly positive urine test for pregnancy -Nausea and vomiting is usually marked -Rapid increase in fundic height. Rapid increase in weight -No fetal heart tones; TOXEMIA -Vaginal bleeding seen as clear, fluidfilled, grape size vesicles

Management
>D & C to evacuate the mole

>Prophylactic course of Methotrexate, the drug of choice for choriocarcinoma >Urine testing for one year to find out if new villi are developing.

2. INCOMPETENT CERVICAL OS
= one that dilates prematurely. It is the chief causes of habitual abortion ( 3 or more consecutive abortions)

What is an incompetent cervix? An incompetent cervix is also called cervical insufficiency. The cervix is the bottom part of your uterus (womb). Normally, the cervix remains closed during pregnancy until your baby is ready to be born. A normal pregnancy lasts for about nine months. An incompetent cervix may begin to open at 4 to 6 months of pregnancy. At this time, the cervix may begin to thin and widen without any pain or contractions. The amniotic sac, also called the bag of water, bulges down into the opening of the cervix until it breaks. This may cause a miscarriage or premature (early) delivery of your baby.

What causes an incompetent cervix? The exact

cause of an incompetent cervix is not known. Some women have an incompetent cervix for no obvious reason. The following may cause an incompetent cervix: 1.An abnormal cervix or uterus. 2.Certain medicines, such as diethylstilbestrol (DES). Your mother may have taken DES when you were inside her womb. 3.Changes in hormones during pregnancy. 4.Damage to the cervix, such as during surgery or after a difficult delivery of a baby. 5. Congenital anomalies

What are the signs and symptoms of an incompetent cervix? There are usually no signs and symptoms of an incompetent cervix. The cervix just slowly thins and opens without vaginal bleeding or labor contractions. You may have one or more of the following: 1.Backache. 2.Discomfort or pressure in the lower abdomen (stomach). 3.Gush of warm liquid from your vagina. 4.Mucous-like vaginal discharge. 5.Pain when passing urine. 6. Sensation or feeling of a lump in the vagina.

How is an incompetent cervix diagnosed? You may
need the following tests:

Pelvic exam: This is also called an internal or vaginal exam. During a pelvic exam, Your caregiver gently puts a warmed speculum into your vagina. A speculum is a tool that opens your vagina. This lets your caregiver see your cervix (bottom part of your uterus). With gloved hands, your caregiver will check the size and shape of your uterus and ovaries. Ultrasound: Sound waves are used to show pictures of the inside of your abdomen. A small handle with lotion on it is gently moved about on your abdomen (stomach). The handle may also be placed in your vagina and can measure the thickness of your cervical tissue.

How is an incompetent cervix treated? You
may need to rest in bed during the last 4 to 6 months of your pregnancy. You may also need one or more of the following: Pessary: This is a plastic or rubber device that may be placed in your vagina to elevate and support the cervix. Surgery: You may have surgery called cervical cerclage to tie the cervix closed. This surgery may be done before you get pregnant or during your pregnancy. Tocolytics: These medicines stop or prevent labor contractions.

ULTRASOUND ( also known as Ultrasonic Echo Sounding or Sonar
Preparation for ultrasound

1. Explain the procedure to the patient, informing her that it is painless and there are no known ill effects 2. Empty the bladder but ask the patient to take 6 glasses of water afterwards in order to dilate the bladder. A full bladder displaces a gas filled bowel and, therefore, permits better visualization of the pelvis and its contents.

*Clinical uses of ultrasound
Diagnose pregnancy as early as 5-6 weeks gestational age b. Can establish that the fetus is increasing in size and, therefore can predict EDC c. Can determine gestational age by measuring the biparietal diameter of the fetal skull ( if it is more than 8.5 cm., it is more than 2,500 gms.) d. Can demonstrate size and growth rate of the amniotic sac e. Can confirm presence, size and location of the placenta Can diagnose multiple pregnancy Can visualize ascites, polycystic kidneys, ovarian cysts, etc. Can determine baby’s sex ( during third trimester and if in cephalic presentation)
a.

S/Sx – first and most constant: painless, bright red vaginal bleeding due to tearing of placental attachment as a consequence of dilatation of the internal cervical os

Diagnosis: roll-over test – assesses the probability of developing toxemia when performed between the 28th and 32nd week of pregnancy Procedure Patient lies in ;lateral recumbent position for 15 minutes until BP has stabilized Then rolls over to supine position BP is taken at 1 minute and 5 minutes after having rolled over Interpretation: if diastolic increases 20 mmhg or more, patient is prone to toxemia.

Types MILD Preeclampsia – S/Sx 1. sudden, excessive weight gain of 1-5 lbs. per week ( earliest sign of preeclampsia) due to edema which is persistent and found in the upper half of the body (e.g. inability to wear the wedding ring) 2. Systolic BP of 140, or an increase of 30 mmhg or more and a diastolic of 90, or a rise of 15mm hg or more, taken twice 6 hours apart 3. Proteinuria of 0.5 gms/ liter or more

SEVERE PreeclampsiaS/Sx BP of 160/110 mmhg Proteinuria of 5 gm/liter or more in 24 hours Oliguria of 400 ml. or less in 24 hours (normal urine output/ day = 1500ml). Cerebral or visual disturbances Pulmonary edema and cyanosis Epigastric pain ( considered an “aura” to the development of convulsions)

●2. ECLAMPSIA – the main difference between pre eclampsia and eclampsia is the presence of convulsions in eclampsia. ●signs and symptoms as in preeclampsia plus: ●increased BUN ●increased uric acid ●decreased CO2 combining power

3.) Management: CBR- sodium tends to be excreted at a more rapid rate if the patient is at rest. Energy conservation is important in decreasing metabolic rate to minimize demands for oxygen. Lowered oxygen tension in toxemia is the result of vasoconstriction and decreased blood flow that diminishes the amount of nutrients and oxygen in cells. In any condition wherein there is a possibility of convulsions, bed rest should be in a darkened, non-stimulating environment with minimal handling. DIET For Mild Preeclampsia- high Protein, high carbohydrate, moderate salt restriction ( no added table salt, including “bagoong”, “patis”, “tuyo” can goods, bottled drinks, preserved foods and cold cuts) Severe Preeclampsia-high protein, high calorie and saltpoor (3gms of salt per day)

Medications Diuretics- Chlorthiazide/ Diuril. Hourly urine output should be at least 20-30 ml. (normally 50-60 ml per hour) S/E: Fatigue and muscle weakness due to fluid and electrolyte imbalance Nursing Care: closely monitor intake and output Digitalis- if with heart failure -Pharmacologic action: Increase the force of contraction of the heart, thereby decreasing heart rate. - Important: should not be given if heart rate below 60/min -Take the heart rate before giving the drug

Potasium supplements- patients receiving diuretics are prone to hypokalemia; if digitalis is given at the same time, hypokalemia increases the sensitivity of the heart to the effects of digitalis. Potassium supplements (e.g. banana) must be given to prevent cardiac arrhythmias. Barbiturates- sedation by means of CNS depression Analgesics: antihypertensives; antibiotics; anticonvulsants; sedatives

MAGNESIUM SULFATE- the drug of choice Actions CNS Depressant- lessens the possibility of convulsions Vasodilator- decreases the BP Cathartic causes a shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted Dosage: 10 GMS. initially, either by slow IV push over 5-10 min, or deep IM, 5 gms/ buttock, then an IV drip of 1 gm. per hour (1 gm/100 ml D10W) IF: Deep tendon reflexes are present Respiratory rate is at least 12 per min Urine output is at least 100 ml in 6 hours

Antidote for magnesium sulfate toxicity: CALCIUM GLUCONATE, 10% IV, to maintain cardiac and vascular tone Earliest sign of magnesium sulfate toxicity: disappearance of the Knee jerk/ Patellar reflex Method of Delivery preferably vaginal, but if not possible, CS will have to be done Prognosis the danger of convulsions is present until 48 hours postpartum

2.DIABETES MELLITUS- chronic hereditary disease which is characterized by hyperglycemia due to relative insufficiency or lack of Insulin from the pancreas which in turn leads to abnormalities in the metabolism of carbohydrates, proteins and fats .A.Diabetogenic effects of pregnancy- many women who have had no evidence of diabetes in the past develop abnormalities in glucose tolerance. -Decreased renal threshold for sugar -Increased production of adenocorticoids, anterior pituitary hormones and thyroxin, -Rate of Insulin secretion

B. Attendant risks Toxemia Infection Hemorrhage Polyhydramnios Spontaneous Abortion- because of vascular complications which affect placental circulation Acidosis- because of nausea and vomiting. It is the chief threat to the fetus in utero Dystocia- due to excessively large baby

C. DIAGNOSIS – MADE ON THE BASIS OF THE Glucose tolerance Test (GTT) Procedure NPO after midnight 2 ml of 50% glucose/ 3 kg of prepregnant body weight is given IV ( oral tablet is not advisable because of known decreased gastric motility and delayed absorption of sugar during pregnancy) Interpretation of results If less than 100 mg% - Normal If 100-120 mg % - possible gestational diabetes If more than 120 mg % - overt gestational diabetes

D. CATEGORIES – TO PREDICT THE OUTCOME OF PREGNANCY Class A – GTT is only slightly abnormal; minimal dietary restriction; insulin not needed; fetal survival is high Classes C to E – have 25% perinatal mortality Class F – therapeutic abortion ( in other countries maybe justified, not in the Phils.)

E. MANAGEMENT Diet – highly individualized. Adequate glucose intake (18002200 calories) to prevent intrauterine growth retardation Insulin requirements are likewise highly individualized, requiring close observation throughout pregnancy. Since the effects of the hormones more pronounced during the 2nd and 3rd trimesters there is increased need for insulin Insulin is regulated to keep urine +1 for sugar ( minimal Glycosuria is necessary to prevent acidosis) but negative for acetone. Long- acting insulin (Ultralente) will have to be changed to regular insulin (Lente) during the last few weeks of pregnancy. Often delivered by CS Baby is typically larger or maybe in distress because of placental insufficiency Severe metabolic imbalances in distress because of depletion of glycogen reserve in the liver and skeletal muscles by strenuous muscular exertion during labor Maximum difficulty in controlling diabetes is during the early postpartum period because of the drastic changes in hormonal levels

INFANT OF THE DIABETEC MOTHER (IDM) 1. Typically longer and weighs more because of: a.excessive supply of glucose from the mother b.increased production of growth hormones from the maternal pituitary gland c.increased secretion of insulin from the fetal pancreas d.Increased action of adrenocortical hormones that favor passage of glucose from mother to fetus 2. Congenital anomalies are often seen 3. Cushingoid appearance ( puffy, but limp and lethargic) 4. More often born premature, so respiratory distress syndrome is common 5. Lose a greater proportion of weight than normal newborns because of loss of extra fluid 6. Are prone to the following complications

A. HYPOGLYCEMIA- blood sugar levels less than 30 mg%. It is the most common complication to watch for Cause: While inside the uterus, the fetus tends to be hyperglycemic because of maternal Hyperglycemia. The fetal pancreas thus responded to the high glucose level by producing matching high levels of insulin. Following delivery, the glucose level begins to fall because the baby has been severed from the mother. Since there has been previous production of high level of insulin, hypoglycemia develops.

Clinical signs of Hypoglycemia shrill, high-pitched cry Listlessness/ jitteriness/ tremors lethargy; poor suck Apnea; cyanosis Hypotonia; Hypothermia Convulsions Consequence : hypoglycemia, if not treated, can lead to brain damage and even death Management: feed with glucose water earlier than usual, or administer IV of glucose B. Hypocalcemia- serum calcium level less than 7mg% a.signs same as hypoglycemia b.Sequela: same as hypoglycemia c.Management: Calcium Gluconate to prevent hypocalcemic tetany

3. Signs and Symptoms 1. Because of increased total cardiac volume during pregnancy, heart murmurs are observed 2. Cardiac output may become so decreased that vital organs are not perfused adequately; oxygen and nutritional requirements, therefore, are not met. 3. Since the left side of the heart is not able to empty the pulmonary vessels adequately, the latter become engorged, causing pulmonary edema and hypertension. Moist cough in gravidocardiacs, therefore, is a danger sign. 4. Liver and other organ become congested because blood returning to the heart may not be handled adequately, causing the venous pressure to rise. Fluid then escapes through the walls of engorged capillaries and cause edema or ascites. 5. Congestive heart failure is a high probability also because of the increased cardiac output during pregnancy. Dyspnea, exhaustion, edema, pulse irregularities, chest pain on exertion, and cyanosis of nailbeds are obvious.

Self-help for pregnancy nausea 1.Ginger is a good way to cope with mild nausea. 2. Eat a bland, starchy diet in small, frequent amounts to help alleviate symptoms. 3.Avoid foods that are fatty or make you feel nauseous. 4.Try taking vitamin B6 supplements, or increasing this vitamin in your diet (bananas, potatoes, watermelon, chickpeas are all rich in this nutrient). 5.Rest frequently. 6.Get regular, gentle exercise. 7.Try sea-sickness acupressure bracelets or acupuncture. 8.If your vomiting is severe, try electrolyte drinks to keep up the levels of minerals and salts that you need.

Medical treatment for hyperemesis gravidarum 1.fluids via a drip 2. anti-nausea medication via a drip 3. vitamins and other nutrients that you may have lost through your severe nausea 4. rarely, nutrients, via a naso-gastric tube or intravenously, if you are still unable to eat and keep food down.

C. ANEMIA -low red cell count maybe underlying condition -may or may not be exacerbated by physiologic hemodilutionn of pregnancy -most common medical disorder of pregnancy s/sx client is pale, tired, short of breath, dizzy Hgb is less than 11g/dl; hct less than 37% MGT. Encourage intake of food rich in iron content Monitor iron supplementation Teach sequelae of iron ingestion Assess need for parenteral iron

D. PRENATAL SUBSTANCE ABUSE 1. ALCOHOL =elvates the mood, depresses the CNS =affects every other system in the body of the mother =displaces other nutritional food intake =greatest risk from high blood alcohol levels =NO SAFE Level of maternal alcohol use in pregnancy has been established =FETUS may display : >IUGR >CNS dysfunction and Craniofacial abnormalities( fetal alcohol syndrome)

7. PRECIPITOUS LABOR AND DELIVERY labor of less than 3 hours emergency delivery without client’s physician or midwife ASSESSMENT Finding As labor is progressing quickly, assessment may need to be done rapidly client may have history desire to push observe for status of membranes, perineal area for bulging, and for signs of bleeding 8. AMNIOTIC FLUID EMBOLISM - escape of amniotic fluid into the maternal circulation, usually in conjunction with a pattern of hypertonic, intense uterine contractions, either naturally or oxytocin induced - OBSTETRIC EMERGENCY: maybe fatal to the mother and to the baby -ASSESSMENT FINDING 1. sudden onset of respiratory distress, hypotension, chest pain, signs of shock 2. bleeding (DIC) 3. Cyanosis 4. Pulmonary Edema

NSG. INT. 1. Initiate emergency life support activities for mother =Administer O2 =Utilize CPR in case of Cardiac Arrest 2. Establish IV line for blood transfusion and monitoring of CVP 3. Administer Meds. To control bleeding 4. prepare for emergency birth of baby 5. Keep client/ family informed as possible

A. TOXOPLASMOSIS - is caused by infection with the intracellular protozoan parasite TOXOPLASMA GONDI - produces a rash and symptoms of acute,flulike infections in the mother - is transmitted to the mother through raw meat or handling of cat litter of infected cats - organsm is transmitted to the fetus across the placenta - can cause spontaneous abortion

B. RUBELLA/ GERMAN MEASLES - is teratogenic in the first trimester - Rubella causes congenital defects of the eyes, heart and brains - If not immune (titer of 1:8 or less ), the mother should be vaccinated in the postpartum period; she must wait at least 3 months before becoming pregnant Incidence: Mother- the earlier the mother contacted the disease, the greater the likelihood that the baby will be affected. The rubella virus slows down division of infected cells during organogenesis, thus causing congenital defects. Newborn- can carry and transmit the virus for as long as 12-24 months after birth Signs and Symptoms of Congenital Rubella Syndrome Low birth weight; jaundice; petechiae; anemia; thrombocytopenia; hepatosplenomegaly Classic Sequelae: a. Eyes: Chorioretinitis, cataract, glaucoma b. Heart: Patent ductus Arteriosus, stenosis, Coarctations c. Ear: Nerve Deafness d. Dental and Facial clefts

1. No sexual activity in the presence of lesions and 10-14 days after lesions subsided 2. Keep vulva clean and dry in presence of lesions 3. Sitz bath and void in water for urinary pain and retention 4. Use of foley catheter if retention persist 5. Povidone-Iodine douche & ACYCLOVIR (not used during pregnancy)

E. SYPHYLLIS Cause: TREPONEMA PALLIDUM A spirochete which enters the body during coitus or through cuts and breaks in the skin or mucous membrane Treatment: 2.4 – 4.8 million units of PENICILLIN – Benzathine Penicillin= DOC ( Antidote: 30-40 grams ERYTHROMYCIN) If untreated, syphilis can cause Midtrimester abortion, CNS lesions in the newborn or even death THE NEWBORN WITH CONGENITAL SYPHILLIS SIGNS AND SYMPTOMS: Jaundice at 2 weeks of life – 1st sign of the disease Anemia and hepatosplenomegaly “SNUFFLES”(persistent rhinorrhea); coppery rashes on palms and soles; mucous patches; condylomas; pseudo paralysis due to bone inflammation If untreated, can progress on to deformed bones, teeth, nose, joints and CNS syphilis Management: Penicillin IM for 10 days or one long- acting Penicillin(Penadur LA)

F. VARICELLA- ZOSTER (CHICKEN POX) - 2% risk of having a child with congenital defects in pregnancy -if infection occurs in the last 4 days of gestation and 2 days postpartum, it results in FATAL NEONATAL INFECTION -s/sx : vesicles on trunk, neck, face and then the extremeties. Varicella pneumonia is quite severe in pregnancy - TX. 1. Strict isolation during dse. 2. Bathe daily to prevent bacterial infection on the vesicles 3. Watch out for varicella pneumonia 4. Varicella-zoster immune globulin within 3 days of exposure to alleviate maternal signs but not alter fetal outcome 5. May breastfed after the dse.

G. GONNORHEA - can cause spontaneous abortion, PROM - if present during delivery it can cause BLINDNESS - profuse and purulent vaginal discharge, itching of the vulva, painful urination and positive in a cervical smear -DOC= CEFTRIAXONE or SPECTINOMYCIN or PROBENECID = 0.5% ERYTHROMYCIN or 1% TETRACYCLINE ointment for babies

8. Cranial Birth Injuries A. CAPUT SUCCEDANEUM: = edema with extravasations of serum into scalp tissues caused by molding during the birth process; crosses the suture lines of the bony plates of the skull; = no tx is necessary; it subsides in a few days. B. CEPHALHEMATOMA: =edema of the scalp with effusion of blood between the bone and periosteum; stops at the suture line; =no tx is necessary; = it disappears within a few weeks to a few months after birth C. INTRACRANIAL HEMORRHAGE = bleeding into cerebellum, pons and medulla oblongata caused by a tearing of the tentorium cerebelli. = occurs in preterm infants and following prolonged labor = difficult forceps birth = precipitate birth or breech extraction

9. Meconium Aspiration Syndrome (MAS) A. hypoxic insult to fetus that causes increased intestinal peristalsis with passage of meconium into the amniotic fluid; =the meconium – stained fluid is aspirated by the infant during the first few breaths after birth causing an obstruction in the lung that results in chemical pneumonia B. Therapeutic interventions: 1. suctioning after head is delivered 2. oxygenation and ventilation 3. prophylactic antibiotic therapy